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dicine & Me S l u Prabhu et al., Trop Med Surg 2014, 2:3 a r ic g e p DOI: 10.4172/2329-9088.1000167 r

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r T Tropical Medicine & Surgery ISSN: 2329-9088

ReviewResearch Article Article OpenOpen Access Access

A Need to Spread Awareness Regarding the Ill Effects of Arecanut and Its Commercial Products on Oral Health Rachana V Prabhu1*, Vishnudas Prabhu2 and Laxmikanth Chatra1 1Department of Oral Medicine and Radiology, Yenepoya University, 2Department of Oral and Maxillofacial Pathology, Yenepoya University, India

Abstract , commonly known as nut or supari, is a fruit of areca palm tree, which is native of South and Pacific islands. The seed or endosperm is consumed fresh, boiled or after sun drying or curing. Areca nut is chewed by itself or in the form of commercial preparations like pan masala and . Chewing areca nut is thought to have central nervous system stimulating effect and along with this it is known to have salivary stimulating and digestive properties. Along with the beneficial effects of areca nut one of its most harmful effects on the human body in general and oral cavity in particular is the development of potentially malignant disorder called . The present paper discusses the ill effects of consumption of areca nut and its commercial products on oral health and a need to spread the awareness regarding the same.

Keywords: Areca nut; Potentially malignant disorders; Oral content known as that leads to alertness, increased stamina, submucous fibrosis; Oral a sense of well-being and . It is known to stimulate salivation and thus aiding in digestion. According to traditional Ayurvedic Introduction medicine, chewing areca nut is a good remedy for deworming and along with betel leaf it prevents halitosis. Along with these beneficial Areca nut or supari is a fruit of palm tree, which is effects of areca nut one of its most harmful effects on the human body native of South Asia and Pacific Islands. It is commonly called as betel in general and oral cavity in particular is the development of potentially nut as it is often chewed wrapped in betel leaves. While fresh, the husk malignant disorder called Oral Submucous Fibrosis (OSF) [4]. is green in color and the nut inside is very soft whereas in a ripe fruit the husk becomes yellow or orange and the fruit inside hardens to a Oral Submucous Fibrosis (OSF) wood like consistency [1]. The seed or endosperm is consumed fresh, boiled, or after sun drying or curing. Areca nut consumed with betel Oral submucous fibrosis (OSF) is a chronic, insidious oral mucosal leaf, lime with or without is called as Pan or betel quid. It may condition that occurs predominantly among Indians and occasionally include , , catechu etc. for extra flavouring [1]. Areca in other Asians especially Taiwanese and sporadically in Europeans. nut is chewed by itself or in the form of commercial preparations like It was first described by Pindborg and Sirsat. It is regarded as a pre- pan masala and gutka [2]. cancerous condition [4]. Pan masala is basically a preparation of areca nut, catechu, The hallmark of the disease is sub mucosal fibrosis that affects cardamon, lime and a number of natural and artificial perfuming and the oral cavity and progressively involves the pharynx and the upper flavouring materials. Gutka or Gutkha is a preparation of crushed esophagus. It is characterized by juxta-epithelial inflammatory reaction areca nut, tobacco, catechu, paraffin, slaked lime and sweet or savory followed by chronic change in the fibro-elasticity of the lamina flavourings [1]. propria and is associated with epithelial atrophy. This leads to burning Both products are often sweetened to enhance the taste. Both are sensation in the oral cavity, blanching, and stiffening of manufactured in India and exported to a few other countries. It is sold and oropharynx, resulting in restricted mouth opening which in turn across India in small, individual-sized packets that cost between 2 and causes limited food consumption, difficulty in maintaining oral health, 10 rupees per packet [2]. and impairs the ability to speak [5]. There is an estimated 600 million people chewing betel nut Although the pathogenesis of the disease is thought to be worldwide. A survey done by Indian Dental Association (IDA) found multifactorial, chewing of betel quid/areca nut has been recognized as that 10% to 14% of school students and 70% of college going students one of the most significant risk factors for OSF [6]. in Mumbai chew gutkha and pan masala [3]. Areca nut primarily consists of like arecoline, arecaidine, guvacine and guvacoline, (Flavonols and ) and Betel nut *Corresponding author: Rachana V Prabhu, Department of Oral Medicine and specific (mainly Saffrole) as its main constituents, which is primarily Radiology, Yenepoya Dental College, Yenepoya University, , Karnataka carcinogenic. Both areca nut containing commercial products are often 515018, India, Tel: 08147020203; E-mail: [email protected] advertised as mouth freshners, leading to a much higher frequency of Received February 24, 2014; Accepted April 18, 2014; Published April 21, 2014 use, so that these younger chewers constitute an alarming population Citation: Prabhu RV, Prabhu V, Chatra L (2014) A Need to Spread Awareness for a new epidemic of [4]. Regarding the Ill Effects of Arecanut and Its Commercial Products on Oral Health. Trop Med Surg 2: 167. doi:10.4172/2329-9088.1000167

Effects of Areca nut Copyright: © 2014 Prabhu RV, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits Areca nuts are chewed with betel leaf for their effects as a mild unrestricted use, distribution, and reproduction in any medium, provided the central nervous system stimulant. The effect is thought due to one of its original author and source are credited.

Trop Med Surg ISSN: 2329-9088 TPMS, an open access journal Volume 2 • Issue 3 • 1000167 Citation: Prabhu RV, Prabhu V, Chatra L (2014) A Need to Spread Awareness Regarding the Ill Effects of Arecanut and Its Commercial Products on Oral Health. Trop Med Surg 2: 167. doi:10.4172/2329-9088.1000167

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A number of etiological factors have been discussed to play a Steps Taken By Government to Ban Areca Nut role in the pathogenesis of this disease. Factors include areca nut Containing Commercial Products chewing, ingestion of chillies, genetic and immunologic processes, and nutritional deficiencies [5]. Highly addictive and a known , gutkha is the subject of much controversy in India. Many states have sought to curb its immense Various epidemiological studies and histopathological effects on popularity by taxing sales of gutkha heavily or by banning it outright. fibroblast and keratinocytes support the chewing of areca nut as one of Many states of India have banned the sale, manufacture, distribution the most important risk factors for OSF [4]. and storage of gutka and all its variants. As of May 2013, gutka is Areca nut is made up of and flavonoid components. Four banned in 24 states and 3 union territories. Gutka is banned under the alkaloids namely arecoline, arecaidine, guvacine, and guvacoline have provision to ban any food product containing harmful adulterants in been identified in areca nut, of which arecoline is the most potent the centrally enacted Food Safety and Regulation (Prohibition) Act agent and plays a major role in the pathogenesis of OSF by causing an 2011. The ban is enforced by the state ministry, the state abnormal increase in collagen production. The flavonoid components Food and Administration and the local police. Enforcement of like tannins and catechins have been found to have some direct the law is generally lax and many shops still sell gutka, although it may influence on collagen metabolism [5]. not be displayed. Enforcemnent is stricter in some regions like Mumbai and Delhi, but illegal sale of gutka still occurs [2]. The tremendous rise in the incidence of this condition has been reported. It is predominently seen in Asian countries like India, Conclusion , , , , Southern , and . Several cases are reported among Asian immigrants to Inspite of strict ban of commercially available areca nut products, the UK and South and East Africa [7]. Gutka and masala continue to be freely available across the state. The alkaloid and flavonoid content of the areca nut plays a very Worldwide estimates in 1996 indicate that 2.5 million people were important role in the major events that occur in pathogenesis of OSF found to be affected by this disease. Whereas in 2002, in the Indian which has a high potential of tuning into malignancy. It is well said continent alone, the statistics for OSF was about 5 million people (0.5% that ‘Prevention is better than cure’ and it holds true in case of the of the population of India) [8]. In recent years marked increase in the management of this irreversible disease. Thus awareness of its ill effects occurrence of OSF was observed in many parts of India like Bihar, MP, and cessation of the areca nut chewing habit forms the mainstay for Gujarat and Maharashtra and the younger generation are suffering the therapy. more due to incoming of areca nut products in different multicoloured References attractive pouches [9]. 1. Betel-quid and areca-nut chewing. The prevalence of OSF among patients attending dental OPD in 2. Javed F, Chotai M, Mehmood A, Almas K (2010) Oral mucosal disorders Jaipur, Rajasthan, India in 2012 was found to be 3.39% [10]. Therefore associated with habitual gutka usage. A review Oral Surg Oral Med Oral Pathol OSF is considered as a public health issue in many parts of world Oral Radiol Endod 109: 857-864. including the UK, South Africa, and many Southeast Asian countries 3. Gupta PC, Ray CS (2004) Epidemiology of betel quid usage. Ann Acad Med [11]. The reason for the continuous rise in the incidence of OSF could Singapore 33: 31-36. be attributed to increased popularity of commercially available areca 4. Angadi PV, Rao SS (2011) Areca nut in pathogenesis of oral submucous nut preparations, i.e., pan masala/gutkha in India and an increased fibrosis: revisited. Oral Maxillofac Surg 15: 1-9. uptake of this habit by young people due to easy access, effective price ranges, and marketing strategies [5]. 5. Sinor PN, Gupta PC, Murti PR, Bhonsle RB, Daftary DK, et al. (1990) A case- control study of oral submucous fibrosis with special reference to the etiologic In 2008, about 5 million children under 15 were addicted to gutkha. role of areca nut. J Oral Pathol Med 19: 94-98. A survey in Uttar Pradesh and Madhya Pradesh found precursors of 6. Jeng JH, Chang MC, Hahn LJ (2001) Role of areca nut in betel quid-associated mouth in 16% of the children [2]. According to the 2009-2010 chemical carcinogenesis: current awareness and future perspectives. Oral survey by Global Adult Tobacco Survey, 53.5% of Indians use tobacco Oncol 37: 477-492. products. Tobacco and gutka chewing makes up the majority of those 7. Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya S figures with 48.07% of Indians using them, while bidi and cigarette (2006) Oral submucous fibrosis: Review on aetiology and pathogenesis. Oral Oncology 42: 561-568. smokers make up 8.4% and 5.9% of the population respectively. The percentage of male and female tobacco and gutka chewers is 66.2% and 8. Chiu CJ, Chang ML, Chiang CP, Hahn LJ, Hsieh LL, et al. (2002) Interaction of collagen related genes and susceptibility to betel quid induced oral submucous 40% respectively [2]. fibrosis. Cancer Epidemiol Biomarkers Prev 11: 646-653. Based on a systematic review of all published literature, 9. Ahmad MS (2006) Epidemiological and etiological study of oral submucous International Agency for Research on Cancer reported that Areca Nut fibrosis among Gutkha chewers of Patna, Bihar, India. J Indian Soc Pedod Prev Dent 24: 84-88. Chewing is strongly associated with oral cancer (IARC monograph). Arecanut chewing has been shown to be associated with development 10. Sharma R, Raj SS, Miahra G, Reddy Y G, Shenava S, et al. (2014) Prevalence of Oral submucous fibrosis in patients visiting dental College in rural area of of cancers of various organs like liver, esophagus (food-pipe), stomach, Jaipur, Rajasthan. JIOMR 24: 1-4. lung, and cervix [2]. The malignant transformation rate of OSF has 11. Rajalalitha P, Vali S (2005) Molecular pathogenesis of oral submucous been reported to be around 7.6% over a 17-year period [12]. OSF is fibrosis-a collagen metabolic disorder. J Oral Pathol Med 34: 321-328. now accepted globally as an Indian disease having highest malignant 12. Pindborg JJ, Murti PR, Bhonsle RB, Gupta PC, Daftary DK, et al. (1984) Oral potential than any oral premalignant lesions [13]. The incidence of OSF submucous fibrosis as a precancerous condition. Scand J Dent Res 89: 270-274. in India is on the rise. The reason for rapid increase of the disease is due 13. Gupta MK, Mhaske S, Ragavendra R, Imtiyaz (2008) Oral Submucous Fibrosis- to the consumption of commercially prepared areca nut preparations Current concepts in Etiopathogenesis. People’s journal of Scientific Research (pan masala and gutka) in India. 1: 39-44.

Trop Med Surg ISSN: 2329-9088 TPMS, an open access journal Volume 2 • Issue 3 • 1000167